A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

Decrease maintenance IV solution infusion rate.

Place the client in a lateral position.

Administer oxygen via face mask at 2 L/min.

Administer misoprostol 25 mcg vaginally.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.

Choice B rationale:

Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.

Choice C rationale:

Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.

Choice D rationale:

Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.

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Correct Answer is D

Explanation

Choice A rationale:

Abdominal distention is not a typical manifestation of hypoglycemia in a newborn. Instead, it can be associated with gastrointestinal issues or other conditions affecting the abdominal organs.

Choice B rationale:

Petechiae are small, pinpoint purple or red spots that appear on the skin due to broken capillaries. They are not related to hypoglycemia and can be caused by various factors such as blood clotting disorders or infections.

Choice C rationale:

Increased muscle tone is not typically associated with hypoglycemia in a newborn. Instead, hypoglycemic babies may exhibit decreased muscle tone, lethargy, and poor feeding.

Choice D rationale:

Jitteriness is a common manifestation of hypoglycemia in newborns. It is characterized by rhythmic tremors, often involving the face and extremities. This occurs because the brain relies heavily on glucose for energy, and low blood sugar levels can affect neurological function, leading to jitteriness. Prompt intervention is necessary to prevent further complications.

A. Blood pressure 136/88 mm Hg. B. Moderate fetal heart rate variability. C. Respiratory rate 100/min. D. Urinary output 120 mL in 2 hr.

Correct Answer is C

Explanation

Choice A rationale:

Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.

Choice B rationale:

Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.

Choice C rationale:

Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.

Choice D rationale:

Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.

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A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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